Fast Fact and Concept #040: Pressure Ulcer Management: Prevention and Staging

2nd Edition

Author(s): Frank Ferris, MD and Charles von Gunten, MD

Poor attention to skin care in the dying patient will result in pain, odor, swelling, reduced quality of life and increased care demands for family and other caregivers. Skin can withstand 30-60 minutes of poor perfusion, but not longer. Pressure ulcers result from ischemia, due to pressure closing the microarterioles, particularly at pressure points--heals, sacrum and elbows. Intrinsic risk factors for the ulcer development are limited mobility, conditions that reduce tissue oxygenation, age-related changes in skin and cachexia. Extrinsic factors are physical forces such as friction, moisture and shear.

Prevention of ulcers is the highest level of care; bedbound patients need to be turned regularly and/or they need a pressure-reducing surface. Skin should be protected from friction, moisture and shear. High-risk areas should have either a thin film or hydrocolloid dressings applied.

Ulcer Progression

Stage I. The heralding lesion of skin ulceration is non-blanchable erythema.

Stage II. Partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and looks like an abrasion or shallow crater or blister.

Stage III. Full thickness skin loss involving subcutaneous tissue. The ulcer may extend down to, but not through, the underlying fascia. The ulcer looks like a deep crater, with or without undermining of adjacent tissue.

Stage IV. The ulcer is deep enough to include necrosis and damage to underlying muscle, bone, and/or other supporting structures such as tendon or joint capsule. Undermining of adjacent skin and sinus tracts may also be present.

Pressure Reducing Surfaces

There are 3 groups of support surfaces that have demonstrated effectiveness; some need to be ordered by the physician.

1. Air or water mattress overlays (e.g. Roho)— ideal for most patients to prevent pressure ulcers. Order for patients at risk for pressure ulcers.

2. Low-air-loss beds (e.g. Kenn-air, Dyna-Care, Sof-Care) can be used for high-risk patients, or patients with existing ulcers to prevent worsening and/or healing.

3. Air-fluidized beds (e.g. Clinatron, Fluid-air) are reserved for patients needing maximum pressure reduction and pressure relief. However, patients frequently describe them as overly confining (even “coffin-like”) and they are very expensive (e.g. Clinitron bed may lease for > $100/day).

Note: Simple foam pads are often ineffective; if they are used, particularly in the home, they should be laid one on top of the other. If a hand is placed under the pads, there should be at least 1 inch of non-compressed foam between the hand and the patient. Never use round cushions (a.k.a. donuts); they occlude blood flow and don’t prevent ulcers. Professional assessment and design is needed for special pressure reducing cushions (e.g. for wheelchairs).

See Fast Fact #41 for discussion of pressure ulcer treatment

References

1. Paul Walker. The pathophysiology and management of pressure ulcers. In:Topics in Palliative Care, Volume 3. Eds. Russell K. Portenoy and Eduardo Bruera. Oxford University Press 1998. Pp 253-270.
2. Paul Walker. Update on pressure ulcers. Principles & Practice of Supportive Oncology Updates 2000;3(6):1-11.

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Copyright/Referencing Information : Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Fast Facts and Concepts #40. von Gunten C and Ferris F. Pressure ulcers: Prevention and Management, August 2005, 2nd Edition. End-of-Life / Palliative Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 5/2001; August 2005, 2nd Edition

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Non-pain symptoms and syndromes